I’ve said this before, and I’ll continue to say it until I can do something about it: The Fee-For-Transport model has failed EMS. We have to change it and we have to change it soon.

In fact, I believe that the entire revenue model we use for our industry has failed. I think that the “Fee for Transport” model employed by the Emergency Medical Services industry is flawed, archaic, outdated, and is not conducive for the development of our profession. I think it stifles growth and development. I think that it is unfair to make this inequity up through local property taxes.

I think it has to change.

Don’t know what I’m talking about? Let’s hear what Medicare has to say on the subject:

“The Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service. When multiple ground and/or air ambulance providers/suppliers respond, payment may be made only to the ambulance provider/supplier that actually furnishes the transport.” (https://www.cms.gov/manuals/Downloads/bp102c10.pdf)

Yes, that’s what that means: Medicare sees EMS solely as a “transport provider.”

Basically Medicare is saying that all they’re going to pay for is taxi service. Sure, they’ll reimburse some other expenses, but without the taxi component, they’re not picking up the tab. They’re certainly not going to pay for you to provide medical care for one of their clients on a scene. They’re not going to pay you for sweetening up an unresponsive diabetic and leaving them at their house, they’re not going to pay you for providing Community Paramedicine, and they’re certainly not going to pay you for other home health or primary care services. To them, we’re a medical transport industry. They pay for transportation and that’s it. Sure, they make a differentiation between “Emergency” transportation and “Non-Emergency Transportation” and use the term “skilled medical treatment” for some of the things done in the back of our rigs, but that whole “transportation” thing is always there. No transport, no payment. It’s as simple as that.

This very appropriate image was sent in to me by Matthew Rausenberg while I was writing this post. Thanks Matt!

I’ll admit, this is pretty light reading by government standards, but it’s important for all of us in the profession to read, understand, and know this stuff. Sure, I know that some of you out there are going to fall back on our old standby statement that “I’m not in this for the money, I just want to help people” or some other platitude just like that, and I understand and appreciate your altruistic motivations… but I will tell you that EMS needs money to operate. Whether you’re a volunteer or a full-time paid employee, your ambulance service needs money to function. Paid employees need to make a living, ambulances need fuel, stations need heat, equipment needs to be replaced, and communities need 24-hour ambulance coverage to meet both their emergency and non-emergency needs. Ambulance services are critical for any community, no matter their capacity, and all of that stuff takes money. Medicare, through the “Centers for Medicare and Medicaid Serivices” (CMS) sets the tone for the entire healthcare payment industry and by default they have become responsible for propping up a majority of ambulance services through providing the lion’s share of their total revenue in some areas. They’re the big dogs in the healthcare payment arena… and they’re holding us back.

Not that I’m solely picking on Medicare here… but let’s read further into their definitions, shall we? (From the second document I linked to above):

“Emergency ambulance transportation

Emergency ambulance transportation is provided after you’ve had a sudden medical emergency, when your health is in serious danger, and when every second counts to prevent your health from getting worse. The following are examples of when Medicare might cover emergency ambulance transportation:

You’re in severe pain, bleeding, in shock, or unconscious.

You need oxygen or other skilled medical treatment during transportation.

You need to be restrained to keep you from hurting yourself or others.

These are only examples. Medicare coverage depends on the seriousness of your medical condition and whether you could have been safely transported by other means.”

Clearly, Medicare thinks that only “Skilled Medical Care” provided whilst tires are rotating under a patient is valuable. They pay no attention to the fact that there are better and cheaper alternatives out there that our profession could offer them. I know that Medicare represents taxpayers and the payments they give out are tax dollars, and I appreciate and want them to be responsible with those tax dollars…

I just don’t think that they are.

Medicare has determined that the only way they can be responsible with our tax money is to deny as many payments as possible and to only pay for the bare minimum that they feel is important. That’s why ambulance services are “Transportation providers” in their eyes. However, this ignores so much potential in cost savings in my opinion. They pay no attention to the fact that while it’s nice that they pay for “Wait-and-return” ambulance transfers to and from nursing homes and clinics, those services could be provided in a lot of cases by paramedics who could take care of the patient’s needs on site and save them a ton of money by offering the new service. They ignore the fact that if they provided a $250-$300 benefit for an ambulance to come, fully assess, treat an unresponsive hypoglycemic diabetic, and then release them safely without transport, they could avoid the (estimated) $500 transport bill and subsequent $1000 ER bill. The savings are potentially enormous… and there are a ton of ideas like that waiting to be explored.

We, as a profession, just have to convince them that these ideas are worth being explored.

The healthcare payment system shapes healthcare. It certainly has shaped the way we operate in EMS. The pressure to do only what we’re going to get paid to do is so prevalent a force in the industry that it is almost the very foundation of what we do and how we’ve evolved. The payment system didn’t evolve to meet our potential; EMS has evolved to fit its limiting influence. This is why we do the BLS transfers that cost too much for too little benefit. This is why new products that can’t be reimbursed aren’t making their way into the hands of field providers. This is why treatment modalities aren’t expanding as fast as in other areas of medicine. The CMS fee schedule dictates all of this.

And we as a profession have to change it.

Imagine what EMS would be today if we could bill for any service we thought provided benefit to our patients and our communities? To be sure, this would cause some “waste, fraud, and abuse” in the initial phases… but that exists in today’s system. Could you imagine if Community Paramedicine was fully reimbursed? Can you imagine that if instead of providing a wait-and-return BLS transport for a nursing home patient needing a surgical wound re-check, you came, assessed, took some pictures on a cell phone camera and sent it to the physician wirelessly? Can you imagine if you could charge for responding, assessing a patient with a minor medical complaint, and then having the patient transported to an urgent care center that would continue your care? Can you imagine how different everything we do could be?

Well, at least I can start to imagine. I see additional revenue streams that would come into our industry and improve the profession, strengthen our patient care, and save the healthcare system a boatload of money while improving access to primary healthcare. I see paramedics and EMTs not being taxi drivers. I see a real career and a bigger impact upon the overall health of our communities. I see more fiscal responsibility. I see lots of great potential.

And I don’t know how to do this yet, but maybe somewhere, someone reading this might have an idea.

Do you?

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I’ve written on this before, and maybe you’d be interested in reading some of those ideas:

While I agree with your overall meme, I do think it’s important to remember the reasons that the CMS regulations came about. Fraud and billing impropriety (and errors) were extraordinary in EMS, and are still occur with significant prevalence.

The structure of many EMS systems creates numerous opportunities for additional fraud, impropriety, and error if reimbursement is not tied to the transporting agency. Should CMS pay for optional services that have presented limited evidence of their efficacy and evidence based grounds for treatment? Community A has ALS everything, and community B had BLS first responders and ALS transport units. Who should get paid in each area? Why should CMS fund Area A and Area B differently, and why should CMS spend th time and effort to determine this? Administratively, why should CMS open the door to multiple agencies billing for the same responses?

EMS nationwide still lacks standardization in service levels despite the NREMT, and there are no recognized standards for additional service levels, nor documented evidence of their efficacy or ROI of CMS dollars in EMS services. The additions of these value added services are at the discretion of the local community, not CMS.

Your hypothesis suggests that all EMS service must be funded federally, which I must disagree with. I would argue that EMS must do better at selling its value to their service area, whom will make the decision whether or not they want to receive the benefits that advanced services would offer them. The problem is the pervasiveness of the paradigm that EMS must be self funded based upon CMS funding, where this is not the case. You’re asking CMS to pay for the Mercedes when the Ford is meets the need, without explaining, documenting, and proving why you need the Mercedes. Your service area is capable of granting you the extra funding for the Mercedes, if you can explain the benefit of it.

I do think that EMS could offer enormous cost benefits to CMS were EMS better integrated with vertical health systems, however there are an equally enormous amount of hurdles to overcome before we get there. Creating the opportunity to capitalize on those opportunities however, lies with us, not CMS. Better medic education, responsibility, licensing, and EMS system accountability all need to be improved before we can really make the case for CMS funded expansion of services.

Skip Kirkwood

There is only one group that can change this – CONGRESS. They made the rules, and even CMS can’t change that. If we were organized, we could GET Congress to change that. But we’re not….we don’t join our associations, pay our dues, play the political game. We sit back and complain, but we don’t DO – so nothing changes.

It’s time for EMS folks to put on their big kid undies and start playing in the adult world like every other profession, industry, occupational group or whatever does. When NAEMT has its offices in Washington DC with a staff of lobbyists and a budget to go around and “influence” senators and representatives then we can do something about this.

This link shows what we aspire to in the UK. We have the advantage of one professional body and a main employer (the National Health Service).

It’s not perfect, it does give some uniformity!

Tj.

Wendyw

Check out the South Australia Ambulance Service – they have developed many of these services that you suggest here, very successfully. Not only are patients getting better, more tailored and more cost effective care, but their providers also have been allowed pathways to develop their careers as a result.

Too Old To Work

The UK and Australia are not the US. Following their lead is not only likely to be unsuccessful, it is impossible right now. The problem is us, not the federal government, not the insurance companies, not the hospitals. It’s us.

EMTs and paramedics in this country are not trained or educated to do primary care, which is what you are talking about. The only real exception to that is diabetic patients whose hypoglycemia we correct and then don’t transport. It’s a write off, but that’s because once we fix that problem, the patient is now asymptomatic and can rightly refuse transport. Although in fact almost every patient we see can refuse transport, few do. I exclude cardiac arrest patients because there are good non financial reasons for not transporting patients who have no reasonable expectation of survival.

So, to fix the problem, EMS needs to be designed from the ground up. To do that, we need to redesign EMS education from the ground up. To do that, we need to improve the pay and benefits of EMS providers, because who is going to spend 2-3 times what they now do on EMS education for no increase in pay. That in turn means that EMS will intrinsically be more expensive.

Socialized medicine is not the answer because we are increasingly seeing that having the government pay for health care increases, not decreases the costs and consequently means increased taxes. Since the taxpayers in this country don’t seem inclined to approve that right now, it’s a non starter.

Finally, the studies have shown that ED overcrowding is not a function of people without primary care flooding EDs, it is in fact a problem of throughput and bed capacity for inpatient units. That is where a majority of hospitals are concentrating their efforts, not in the ED itself.

The problem is complex and EMS can not fix it by itself. Which of course brings in other groups who ARE trained in primary care and coincidentally have a job shortage right now. Nurses. If our education level bumps up against theirs, they are (rightly) going to complain that they should be the people going out to people’s homes and doing primary care. Guess where that leaves us? Yup, as drivers for nurses, who have some skills that might be needed for a few patients.

Be careful what you ask for, because you might get it and then find out that it’s not what you really wanted in the first place. Then you can’t change it back.

http://emseducation1.blogspot.com/ Bill

TOTW wrote, “So, to fix the problem, EMS needs to be designed from the ground up. To do that, we need to redesign EMS education from the ground up. To do that, we need to improve the pay and benefits of EMS providers, because who is going to spend 2-3 times what they now do on EMS education for no increase in pay.”

Throughout the argument of which comes first, the pay or the education, TOTW has hit the nail on the head. Let’s admit right up front that money runs medicine. Say it with me, “Money runs medicine”. There now, don’t you feel better?

If we want to improve EMS and at the same time increase reimbursement, we have to be able to cull out the undesirables. When one can earn more at their local McDonalds than an entry wage as an EMT, that speaks volumes as to what is valued.

When counseling students as to what direction they want their educational career to take it is hard to defend against two years to be a paramedic, make $12 an hour or two years to be a nurse and double that.

I agree with everybody that put in thier two cents and everything said is true. If we want the people up there to understand the importance of ems why dont the ems community stop their services for one day may be two just to see how important they are. Nurses are great especially the ones at the ED’s but home health nurses get paid more and that is the reality . Ems personel risk alot going to calls and personel at the ED’s. Restructuring ems from the ground up is a good idea but continuing education for those that already have their certs in other fields eg.( wound care, bandage dressing, and taking care of patients at home) would be petter. I would like alot if emergency EMS and non emergency ems get treated alot better and with respect its a much needed service.

Anonymous

Hello

It’s a nice article it will help my research.

Thanks

Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.

Andrew RandazzoWhy do Ambulances Carry Epi-Pens?Interesting. I've never heard of ambulances carrying EpiPens. I've worked in Wisconsin and Tennessee. Both places have always allowed EMT-B to draw up from Epi ampules. However, when seconds count, I could see EpiPens being something EMTs and Paramedics could benefit from. It's just costly.
2015-03-18 09:34:00

totwtytrWhy do Ambulances Carry Epi-Pens?It's definitely faster and it's accurate. There's really no down side to it at all. Other than the fact that some people give it when it's not needed, but that's not dose related.
2015-03-17 21:01:00

DoYouKnowShitFuck?Colorado CRNAs Vs. Virginia Physicians? An interesting feud for EMSThey "choose" it because the administrative portion of billing for service is a nightmare. Who doesn't just want to clock in, do the job, and go home? Some of you people must've never set foot in a hospital or dealt with docs in any capacity. Pay your tuition and you'll make it through med school.
2015-03-17 00:18:00